Oz and Aphorisms

I’ve frequently written that medicine is hard work. It’s work for the doctor, work for the patient, and work for the society as we make national decisions about health care. There are few shortcuts in the prevention and treatment of disease. It takes ongoing research at the bench and at the bedside, and then sorting through the chaos as the battle plan meets the enemy. Real people don’t always behave as the textbooks suggest, and even if we know, say, that quitting smoking saves lives, we can’t always make it happen.

This is why I find simplistic medical aphorisms to be so offensive. They are rarely helpful, sometimes harmful, and give a distorted view of what medicine can and cannot do. An apple a day does not keep the doctor away, and although a diet that relies more on fruits and vegetables is beneficial, it is no guarantee of anything.

Dr. Oz and other medical charismatics love aphorisms. They make good sound bites, they’re easy and quick to read, and consumers love them, but cui bono? Certainly not patients and others seeking to improve their health. These naive maxims serve only the narcissistic and economic needs of modern medicine men.

A reader pointed me to this particular piece at Dr. Oz’s website, which reads more like an add on the back of a glossy magazine than useful advice from a real doctor. It’s called “28-Days (sic) to Prevent a Heart Attack.” Heart attack prevention happens to be something I know a bit about. Primary prevention (preventing a first heart attack) and secondary prevention (preventing subsequent heart attacks) is one of an internists most important tasks, given that heart disease is one of the three top killers of North Americans. We’ve gotten very good at this through helping people stop smoking, encouraging proper exercise and dietary habits, and treating diabetes, high blood pressure, and high cholesterol. We have decades of data to guide us (and as an engineer recently pointed out to me, without data, it’s just another opinion).

So what does Dr. Oz recommend?

Week 1: artery maintenance. Oz’s recommendation: flax seed oil, baby aspirin, and stretching. The real data? Avoid tobacco, keep a healthy cholesterol level and blood pressure through diet, exercise, and drugs when needed, and control diabetes. Aspirin as primary prevention is a bit controversial. We know it can prevent a first heart attack, but we also know that in people without many risk factors, the rate of complications from aspirin therapy may negate its benefits. In secondary prevention, aspirin saves lives unequivocally.

Week 2: challenge your heart. He recommends exercise. This is not controversial.

Week 3: lower your blood pressure. He recommends fruits and vegetables. The more complex answer? Dietary changes can help control blood pressure. Certain diets, such as the DASH diet, have been proven to help lower blood pressure, but that is different from “controlling” blood pressure. To prevent heart disease, blood pressure should be kept within a certain range, one that is sometimes achievable through diet and exercise, and sometimes not.

Week 4: reduce stress. Seems reasonable. This isn’t as potent a risk modification as the others, but it’s not a bad thing.

Have your risk for heart disease assessed by a professional. Some useful—although imperfect—tools exist to put a number on your risk, such as the Framingham Heart Score.

Identify the most important risk factors in your life: smoking, cholesterol problems, high blood pressure, and diabetes. Work with your doctor to develop a life-long strategy to lower your risk. You may need drugs to help with any of these, you may not. In some cases, if you already have heart disease, the data show that you almost certainly will need drugs to prevent further heart attacks.

Don’t give up. In quitting tobacco, relapse is the rule. When you relapse, go back to your doctor for help rather than giving up. Missing medications, giving up on exercise, returning to bad dietary habits are all common, and rather than avoiding your doctor in fear of getting a finger-wag of shame, go back and ask for help.

There are no simple, magic answers. There is no one plan, one pill, one supplement, or one doctor who can help you avoid heart attacks. Every family medicine doc, internist, and cardiologist is trained in this, and the best ones keep up with the data as it changes, and can help apply what we know to you as an individual. No TV show or website (including this one) has answers that are applicable to everyone or that are always effective. Have questions for your doctor? Write them down and ask, and if you can’t get satisfactory answers, find another doctor (remembering that sometimes the correct answer is “I don’t really know”).

Everyone knows that good eating and exercise are good. Having someone repeat it over and over, and telling you it is a sure thing to prevent heart attacks is idiocy. Set goals, aim toward them, and use the data to guide you.

My blood pressure has been wonderful since I quit smoking. My triglycerides are pretty high, but my oncologist has prescribed some medication to see if we can’t adjust it a bit. I’ve cut out some saturated fats, too.

Both of my parents and three of my grandparents died as a result of heart disease. My cardiac health, though less in my mind, is more important to me than what’s going on with the cancer. Why? I don’t need to change my life to take care of Hodgkin’s lymphoma.

Dianne

Survivors of Hodgkin’s are at higher than average risk for subsequent heart disease and second cancers. Keep up the good work with the heart disease prevention and remember to get screened for other cancers, as appropriate. Best of luck with the transplant!

Medivh

…rather than avoiding your doctor in fear of getting a finger-wag of shame, go back and ask for help.

Easy to say. Extremely easy to say if you’re a doctor who isn’t into shaming. The number of stories I’ve read about primary care physicians who treat inability to comply as unequivocally evil combined with the extreme difficulty of changing PCPs under the current system of HMOs… A lot of people are avoiding healthcare because doing so is more healthy than not. The extreme stress of dealing with a PCP who refuses to deal with your major problems until you meet some criteria, combined with the double whammy of you barely, if at all, being in control of your meeting said criteria and being unable to see another PCP mean that every visit to the doctor is guaranteed excess stress and potential wasted time.

Take for example your scenario of a relapsing smoker. It’s not the majority scenario that I read about most, but it works. Tobacco addiction relapse is, as you’ve stated, more common than not. With work, every tobacco addict can get the monkey of their back, but it’s unlikely to happen the first or second time. There are PCPs out there who will refuse to do anything in the way of, let’s say, heart health until the patient is “fully committed”. That is, complete lifestyle change including throwing down the tobacco addiction. The tobacco addict is expected to do so on the first try with few if any aids; anything less shows incomplete commitment. Until this has happened, discussion of which types of medications may be appropriate will not be held by these types of PCPs. And while they aren’t doing what you or I understand to be medicine, they are the first contact some people have when they need medical attention. Occasionally, they’re the only contact outside of an emergency medicine department that people have access to.

Discounting such problems in the one sentence quoted is probably not helpful to the people it’s applicable to.

Alexis

Or, worse, the fat-shaming doctor. You (then aged 31) walk in with cholesterol of 267, triglycerides of 350, BP of 150/100, and a horrible family history of heart disease, and the doctor says “You need to lose weight.” No, really? If I weigh 270, not 170 (as a 5’8″ woman) there’s no way I don’t already know this, yet there’s a sizable subset of doctors who think that as well as being fat, I am both blind and ignorant. Yet, some docs will postpone doing something they can do NOW in favor of pushing weight loss, which may be the long term solution (if it’s achievable) but leaves the patient walking around with uncontrolled hypertension.

Coda to this story: I lost 50 lbs, my BP got worse and while my cholesterol improved a bit, it’s still too high.

PalMD

This goes along with my opposition to the punitive model of alternative medicine, where proven medical treatment is eschewed in favor of alternative med and lifestyle mod, putting the patient at risk for a longer period of time.

I prefer to treat patients until/unless their lifestyle actually changes rather than punishing them for “failing” to do what I say.

Airedalelover

There is no substitute for a good family doctor for heart (and other) health. My intake interview with mine was wonderful and at the end he looked me in the eye and with great kindness and concern said I needed to stop smoking. I did, with his help, eventually. The point is, he helped me quit and supported me through the relapses – one that came two years after I quit. He doesn’t shame, he supports. My gum dentist, on the other hand, fired me from his practice because I didn’t quit smoking when he told me to. I haven’t recovered from that and have dental issues as a result of not even trying to find another dental specialist for gum disease.

Natalie Sera

My father had early heart disease, with his first heart attack before the age of 53. I had a major coronary artery spasm in 1992, when I was 44. And I have diabetes.
The good part? I have a cardiologist who listens to me and doesn’t try to brush off chest pain as GERD, lung problems or sore ribs. I do as best as I can with my side of the equation and he does the best he can with his. Unfortunately not all doctors are so cautious and caring, and many of them are falling down on their side of the equation.

A Los Angeles Cardiologist

Your post is terrific. I agree that he first step for most people in preventing heart disease is to have their risk assessed. A risk assessment can identify those areas in which a patient can work on to lower the overall risk of cardiovascular disease. I also concur that there is no magic bullet and that risk reduction involves a multi-step approach.

The Blind Watchmaker

Karen Swim

Your post so beautifully articulates why in an age where there is seemingly access to a wealth of health information for the consumer, we are not making as much progress in our quest for better health. We know the sound bites about eating well but can’t read food labels, most are not even aware of how many calories they should be eating in a day so when presented with info they have no idea what to do with it. We know the glossy facts about prevention but haven’t a clue how genetics, risk factors and more make it a little more complicated than a quick fix. Thank you so much for being a voice of truth and reason willing to go beyond the sound bite to truth.

Gonzo

Karen’s comment reminds me of an article I read about teaching critical thinking. Everyone wants to teach it and agrees that it’s a good thing, but you can’t really teach critical thinking without teaching (or from the student’s perspective, learning) the background information about the subject. So people need to understand the basics of nutrition/chemistry/biology before they can really go about the process of determining how to “eat well”.

Writing this it occurs to me that another place that “alternative” medicine hurts is undermining the learning process by avoiding or outright lying about the basic science behind the disease states they claim to cure.